Basic Information
| Provider Information | |||||||||
| NPI: | 1114929684 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIVE STAR QUALITY CARE-NE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTENNIAL PARK RETIREMENT VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 CENTRE STREET | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024582094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177968387 | ||||||||
| FaxNumber: | 6177968375 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 CENTENNIAL CIRCLE | ||||||||
| Address2: | |||||||||
| City: | NORTH PLATTE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 691016586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3085347000 | ||||||||
| FaxNumber: | 3085348216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6177968387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIVE STAR QUALITY CARE-NE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 47-0704192/11 | NE | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 47-0704192/00 | NE | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 47-0704192/11 | 05 | NE | MEDICAID | 47-0704192/00 | 05 | NE | MEDICAID |